Charting a New Course for Nursing Documentation
Oct. 19, 2015 Update
Rollout Schedule:
Adult Acute Care Units Group 2 – 10S; S74, 64, 44, 34, CRC (10-20-15 go live)
Peds Acute Care Units – 6th and 7th floors, VCH (10-27-15 go live)
Adult Acute Care Units Group 3 – 9N, 9S, 6N, 11N (11-3-15 go live)
ICUs Group 1 – PCICU, PICU, VCH; 10N, 11S, VUH (11-11-15 go live – NOTE -- this is a Wed.)
ICUs Group 2 – 10T3, 9T3, 8T3 (11-17-15 go live)
Thanksgiving Week Break
ICUs Group 3 – 5N, 5T3 COBS, 6T3, 7T3, S54 Palliative Care (12-1-15 go live)
EDs – Pediatric and Adult Inpatients boarding in the EDs (does NOT include documentation on Treat and Release patients) (12-8-15
go live)
Focus Topic for this Week:
1. Problems, Priority Problems, Goals, and Response to Care/Recommendations : Common Issues and Correct
Steps --
For access to FAQs, Training Information, and other Resources:
http://www.mc.vanderbilt.edu/root/vumc.php?site=sss2&doc=47409
1
Of 4 pages total
Summary of Issues Resolved since last week (see screenshots below):
Issue
1. % Meal Intake needed
2. Unable to locate Catheter &Perineal Care for
patients with indwelling urinary catheter
3. Interventions to prevent or treat Skin
Breakdown are being missed
4. Some elements were not consistent with ALL
CAPS vs. Mixed Upper and Lower Case
convention (where ALL CAPS = required every
patient at least once per shift)
5. Some options for Isolation were outdated &
there was no way to record when isolation is
discontinued
1.
2
Of 4 pages total
Resolution
Ability to document % of food intake will return to
Assessment, All Docs, and Care Assist2 tabs in Fluid/Nutrition
section
Catheter Care removed from Hygiene section in Self-Care
category; New Peri-care/Catheter Care added to Catheter
Interventions in Urinary Renal section of Intervention and All
Docs tab
On Interventions and All Docs tabs, several items are moved
up closer to Skin/Wound Care section for better visibility
Some items in Falls/Safety section were changed to more
accurately reflect required vs. optional fields.
“Enhanced precautions” and “Discontinued” added to
dropdown. Remember, isolation is documented once per
shift while in effect.
2. In the RENAL/UR All section under Catheter Interventions - Peri-care/catheter care has been added to the
dropdown list.
3. In Self-Care (ADL) under Hygiene/ADL Interventions – removed catheter care but left perineal care.
4. On the ALL DOCS and Interventions tabs under Skin Section – Pressure Ulcer Care/Interventions, ”Mouth
Care/Interventions”, and “Skin Breakdown Control” have been moved up to display just under Incision/Wound
template.
3
Of 4 pages total
5. On the ALL DOCS and INTERVENTIONS tabs under FALLS RISK/SAFETY RISK All – FALLS RISK/SAFETY RISK
Assessment is now in all caps “Falls/Injury precaution”, “Violence control”, and “FALLS RISK/SAFETY RISK
Injurious behavior” have been moved up above the Fall Event templates.
6. On ALL DOCS and on INTERVENTIONS tabs under Metabolic/Isolation –
Removed “Reverse Isolation” and added “Enhanced Precautions” and “Discontinued”.
7. On VITALS I&O – Interventions sections - removed “Interventions”.
4
Of 4 pages total